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Objective: To determine whether discontinuing active screening for vancomycin-resistant Enterococcus (VRE) in Alberta, Canada, acute-care facilities had an associated impact on the rate of rise of hospital-acquired (HA) VRE bloodstream infection (VRE-BSI). Setting: Acute-care facilities in Alberta, Canada. Patients: All patients who were admitted to Alberta Health Services or Covenant Health acute-care facilities between January 1, 2013, and March 31, 2020, and who met the definition for hospital-acquired VRE-BSI were included in the analyses. Methods: An intervention time-series Poisson regression was used to determine the slope change in VRE incidence between the pre- and postintervention (screening) periods. The patient population was separated into 3 cohorts: group 1 (low risk, VRE screening stopped), group 2 (high risk, VRE screening stopped), and group 3 (high risk, VRE screening continued). For all groups, a level- and slope-change model was used. Results: We did not find a statistically significant difference in the slope change or rate of rise in VRE-BSI before and after the intervention, with incidence rate ratio (IRRs) of 1.015 (95% confidence interval [CI], 0.982–1.049), 1.025 (95% CI, 0.967–1.086), and 0.989 (95% CI, 0.924–1.059) for groups 1, 2 and 3, respectively. Conclusions: In Alberta, the rate of HA VRE-BSI has remained consistent, and our findings indicate that there has been no increase in the rate of rise of HA VRE-BSI in sites or units that discontinued screening for VRE, regardless of patient risk group.

Background Secondary mitral regurgitation (SMR) is associated with adverse outcomes and the optimal treatment modality remains challenging due to extensive variety in the pathology of SMR. Percutaneous direct annuloplasty using the Cardioband system emerged as a promising treatment in selected patients. However, success predictors of this intervention and their association with prognosis remain unclear. Purpose To investigate the role of echocardiographic and computed tomography (CT) data in patients with SMR undergoing percutaneous direct annuloplasty. Methods We retrospectively analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband system for SMR at five tertiary centres in Germany and Switzerland between 2013 and 2020. Patients with procedural success (defined as postprocedural MR grade ≤2+) were compared to those with MR >2+ with respect to baseline echocardiographic data and outcome. Results We included 130 patients (median age 75.5 [71–79], 37% female). Most patients were severely symptomatic (NYHA class III/IV 86.9%), had a median EF of 39 (29–52) with an ischaemic etiology in 39%. Procedural success was achieved in 68%. Procedural time was 178.5 (147.5–214.5) minutes. Patients with and without procedural success differed significantly in measures of MR severity (defined as postprocedural SMR severity (grade, vena contracta (VC), effective regurgitation orifice area and regurgitation volume), annular dilatation (leaflet length, LA sphericity index at end-systole and CT-derived intercommissural distance) and leaflet tethering (tenting area, regurgitation jet direction). In multivariable analysis of echocardiographic parameters including significant measures of annular dilatation and leaflet tethering, predictors of procedural treatment success were tenting area (OR 0.54; 95% CI 0.33–0.98 per mm2, p=0.016) and central regurgitation jet direction (OR 2.96; 95% CI 1.06–8.25, p=0.038). After adding CT data in the multivariable model, intercommissural distance proved to be the most significant predictor (OR 0.96; 0.92–0.99, p=0.009), whereas VC was the only echo predictor (OR 0.84; 0.73–0.98, p=0.03). NYHA class III/IV at last follow up was significantly different between groups, with 34.1% vs. 55.2% of patients with vs. without procedural success, respectively (p=0.04). The combined endpoint of mortality or reintervention at 1 year was significantly lower in patients with procedural success (27% vs. 63%, p=0.002), whereas the association of procedural success with 1-year mortality was of borderline significance (13% vs. 32%, p=0.05). Conclusion Two thirds of patients undergoing transcatheter direct annuloplasty for SMR had procedural success. Careful patient selection by assessment of mitral valve anatomy is helpful to predict procedural success, which translates into less symptom burden and better clinical outcome. Funding Acknowledgement Type of funding sources: None.

Background Heart failure with reduced ejection fraction (HFrEF) and secondary mitral regurgitation (SMR) are closely related. Progression of HFrEF-SMR is associated with characteristic pathophysiological changes. Recently, staging of HFrEF-SMR patients showed prognostic value in a SMR cohort on medical therapy. Whether these stages are prognostic for SMR patients undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) in addition to drug therapy is unknown. Purpose The present study aimed at classifying HFrEF-SMR patients undergoing M-TEER into progressive disease stages based on cardiac and extracardiac involvement. We sought to evaluate the impact of the disease stages on survival outcome and symptomatic improvement after M-TEER Methods Based on echocardiographic transthoracic evaluation, patients were assigned into one of the following subsequent HFrEF-SMR stages representing disease progression (Figure 1): left ventricular (LV) dysfunction alone (Stage 1, LV end diastolic volume ≥159 ml and/or LV ejection fraction 34 ml/m2); right ventricular (RV) pressure/volume overload (Stage 3, tricuspid regurgitation ≥3+ and/or systolic pulmonary artery pressure >65 mmHg); biventricular failure (Stage 4, RV to pulmonary artery coupling Results Among a total of 849 included patients who underwent M-TEER for symptomatic MR from 2008 until 2019, 9.5% (n=81) presented with LV dysfunction alone, 46% (n=393) with LA involvement, 15% (n=129) with pressure/volume overload and 29% (n=246) with biventricular failure. At baseline and follow-up, successive HFrEF-SMR stages were associated with more severe heart failure symptoms as expressed by NYHA functional class. An increase in HFrEF-SMR stage was associated with increased two-year all-cause mortality rates after M-TEER (Hazard ratio 1.39, confidence interval 1.23–1.58, p Conclusions Classifying HFrEF-SMR patients undergoing M-TEER into subsequent disease stages provides prognostic value regarding heart failure symptoms and survival. Funding Acknowledgement Type of funding sources: None.

Background Following up on the original EVEREST criteria and several years of procedural experience, the German Cardiac Society (GCS) proposed refined criteria indicating morphological complexity in transcatheter edge-to-edge mitral valve repair (TEER) procedures which so far have not been validated. Methods In a retrospective analysis of transesophageal echocardiography images of consecutive patients undergoing TEER in two high-volume centres, complexity was classified according to GCS criteria as optimal (neither characteristics of “complex” nor “very complex', see Table 1), complex (any of the “complex” criteria but no “very complex” criteria) and very complex (any of the “very complex” criteria). Associations with the procedural outcome, reintervention, survival, and heart failure rehospitalization were tested. Results 633 patients (mean age 79 years, range 50 to 96 years, 59% male) were included, with 35% having dominant primary and 65% having dominant secondary mitral regurgitation (MR). 19% of patients were classified as having optimal, 40% as complex, and 41% as very complex morphologies. Successful clip implantation and reduction in MR ≤2 at discharge were achieved in 100% and 97% in the optimal, in 96% and 88% in the complex, and in 95% and 88% in the very complex morphologies, respectively (p for difference 0.13 and 0.42). The rate of successful clip deployment was significantly lower and the rate of reintervention significantly higher in patients with a mitral valve orifice area ≤3 cm2, compared to patients with a mitral valve orifice area >3 cm2. Pathology extent of MR likely requiring >2 clips was significantly associated with a lower rate of MR reduction to grade ≤2. Midterm (median follow-up time 640 days) mortality or hospitalization due to heart failure was significantly higher in patients with a posterior mitral leaflet length of 7–10 mm. Conclusion In the setting of experienced heart valve centres only a few of the complexity criteria proposed by the GCS impact on procedural and clinical outcomes. Even in the case of complex or very complex mitral valve morphology, TEER can be performed effectively with reduction of MR to ≤2 in 88% of cases. Funding Acknowledgement Type of funding sources: None.

Aims Improved imaging modalities contributed to increasing disease awareness of cardiac amyloidosis. Contemporary data on frequency trends and impact on health system are lacking. Methods and results In a retrospective study using health claims data of the largest German statutory health insurance patients with a diagnostic code of amyloidosis and concomitant heart failure or cardiomyopathy between 2009 and 2018 were identified. Temporal trends in frequency, patient characteristics, all-cause mortality and measures of health care burden were examined. 8,279 patients were identified of whom 5,618 were incident without diagnosis of amyloidosis within the previous year. Prevalence increased from 15.5 to 47.6 per 100,000 person-years, and incidence increased from 4.8 to 11.6 per 100,000 person-years, with a continuous steepening in the slope of incidence trend. Age and male gender significantly increased whereas prevalence of myeloma and nephrotic syndrome significantly decreased over time. Median (IQR) survival time after first diagnosis was 2.5 years (0.5 to 6 years), with a 9% (95% CI 2–15%, p=0.008) reduced risk of death in the second compared to the first five years of observation. In the first year after diagnosis mean total health care costs were 21,955 € (median 9,873 €, IQR 3,922 to 24,714 €) per person. Conclusion The rise in patients with cardiac amyloidosis has continuously accelerated in the last decade which, based on patient characteristics, is mainly driven by underlying wildtype transthyretin amyloidosis. Considering the adverse outcome and high health care burden further effort should be put on early detection of the disease to implement treatment. Funding Acknowledgement Type of funding sources: None.

Child welfare service providers in the United States are increasingly acknowledging the importance of engaging youth with foster care experience in case planning, policy advocacy, and practice chan...

BACKGROUND: Concurrent chemotherapy and thoracic radiotherapy followed by prophylactic cranial irradiation (PCI) is the standard treatment in limited-disease small-cell lung cancer (LD-SCLC), with 5-year overall survival (OS) of only 25% to 33%. PATIENTS AND METHODS: STIMULI is a 1:1 randomised phase II trial aiming to demonstrate superiority of consolidation combination immunotherapy versus observation after chemo-radiotherapy plus PCI (protocol amendment-1). Consolidation immunotherapy consisted of four cycles of nivolumab [1 mg/kg, every three weeks (Q3W)] plus ipilimumab (3 mg/kg, Q3W), followed by nivolumab monotherapy (240 mg, Q2W) for up to 12 months. Patient recruitment closed prematurely due to slow accrual and the statistical analyses plan was updated to address progression-free survival (PFS) as the only primary endpoint. RESULTS: Of the 222 patients enrolled, 153 were randomised (78: experimental; 75: observation). Among the randomised patients, median age was 62 years, 60% males, 34%/65% current/former smokers, 31%/66% performance status (PS) 0/1. Up to 25 May 2020 (median follow-up 22.4 months), 40 PFS events were observed in the experimental arm, with median PFS 10.7 months [95% confidence interval (CI) 7.0-not estimable (NE)] versus 42 events and median 14.5 months (8.2-NE) in the observation, hazard ratio (HR)= 1.02 (0.66-1.58), two-sided P= 0.93. With updated follow-up (03 June 2021; median: 35 months), median OS was not reached in the experimental arm, while it was 32.1 months (26.1-NE) in observation, with HR= 0.95 (0.59-1.52), P= 0.82. In the experimental arm, median time-to-treatment-discontinuation was only 1.7 months. CTCAE v4 grade =3 adverse events were experienced by 62% of patients in the experimental and 25% in the observation arm, with 4 and 1 fatal, respectively. CONCLUSIONS: The STIMULI trial did not meet its primary endpoint of improving PFS with nivolumab-ipilimumab consolidation after chemo-radiotherapy in LD-SCLC. A short period on active treatment related to toxicity and treatment discontinuation likely affected the efficacy results.

The number of high-risk patients undergoing surgery is steadily increasing. In order to maintain and, if necessary, optimize perioperative hemodynamics as well as the oxygen supply to the organs (DOTo present a stepwise algorithm for a perioperative echocardiography-based hemodynamic optimization in noncardiac surgery high-risk patients. In this context, echocardiography on demand according to international guidelines can be performed under certain conditions (hemodynamic instability, nonresponse to hemodynamic treatment) as well as in the context of a planned intraoperative procedure, mostly as a transesophageal echocardiography.Hemodynamically focused echocardiography as a rapidly available bedside method, enables the timely diagnosis and assessment of cardiac filling obstructions, volume status and volume response, right and left heart function, and the function of the heart valves.Integrating all echocardiographic findings in a differentiated assessment of the patient's cardiovascular function enables a (patho)physiologically oriented and individualized hemodynamic treatment.HINTERGRUND: Die Zahl der kardiovaskulären Hochrisikopatienten, die sich einer Operation unterziehen, nimmt stetig zu. Um bei dieser Patientenpopulation die perioperative Hämodynamik sowie das Sauerstoffangebot an die Organe (DOIm Folgenden wird ein schrittweiser Algorithmus für eine perioperative echokardiographiebasierte hämodynamische Optimierung bei nichtherzchirurgischen Hochrisikopatienten dargestellt. Dabei kann sowohl eine Echokardiographie „bei Bedarf“ entsprechend den internationalen Leitlinien unter bestimmten Bedingungen, wie z. B. hämodynamischer Instabilität, Nichtansprechen einer hämodynamischen Therapie, erfolgen, als auch im Rahmen einer geplanten intraoperativen Anwendung – meist als transösophageale Echokardiographie.Die hämodynamisch fokussierte Echokardiographie erlaubt als bettseitige, schnell verfügbare Methode die Diagnose und Beurteilung von kardialen Füllungsbehinderungen, des Volumenstatus und der Volumenreagibilität, der Rechts- und Linksherzfunktion sowie der Klappenfunktion.In Zusammenschau aller echokardiographischen Befunde sind eine differenzierte Beurteilung der kardiovaskulären Funktion des Patienten und somit eine (patho)physiologisch orientierte und individualisierte hämodynamische Therapie möglich.

The Grenoble Hybrid magnet is a modular platform using resistive and superconducting technologies to produce various continuous high magnetic field and flux configurations for the scientific community. They range from 43 T in 34 mm diameter with 24 MW electrical power to 9 T in 800 mm diameter when the superconducting coil is used alone. Thanks to the ongoing upgrade of the electrical power installation of LNCMI-Grenoble up to 30 MW and possibly to 36 MW, the possibility to increase the total field up to 45-46 T in the near future is foresee and deeply studied. The key design parameters will be briefly recalled including the specifically developed Nb-Ti/Cu conductor, the large bore outsert superconducting coil, the magnet cryostat with its structure including the eddy-current shield, the cryogenic line for the interconnection with the cryogenic satellite and the fully dedicated 150 l/h He liquefaction plant. All components of the hybrid magnet platform have been built, tested and delivered to LNCMI-Grenoble, where integration and assembly are ongoing. The status of the project will be given with focus to the recent commissioning tests of the cryogenic satellite producing the pressurized superfluid He at 1.8 K as well as to the successful powering tests of the specially developed current leads at ultimate current and under fully degraded cooling conditions simulating the worst-case accidental scenario.

Functional mitral regurgitation (FMR) is characterized by a dilatation of the mitral valve annulus resulting in an insufficient adaptation of the anterior and posterior mitral valve leaflets and/or severe tethering of the leaflets due to dilatation of the left ventricle. The Cardioband® system was introduced in 2015 and is a catheter-based direct mitral valve annuloplasty procedure for treatment of FMR. In the European CE approval study 60 patients with moderate or severe FMR were analyzed per protocol. There were no device or procedure-related deaths. The technical success rate of the procedure, defined as successful implantation and tightening was 97%. At 1 year, the overall survival and survival free of hospital readmission for heart failure were 87% and 66%, respectively. Currently, various interventional treatment procedures are available, such as the edge-to-edge technique as well as direct and indirect annuloplasty. In summary, patients with FMR as a result of a dilatation of the mitral valve annulus appear to be suitable for direct annuloplasty with the Cardioband® system.

Recent advances in the medical oncological treatment options for cancer have led to a clear improvement in the survival rate worldwide; however, many of the recently developed new drugs are directly or indirectly associated with cardiovascular side effects. Cardiovascular diseases are already the most frequent non-cancerous cause of death in tumor patients. Prevention, early detection of these complications, correct management and timely initiation of specific cardiac medical treatment are the key for an improvement of the cardiovascular prognosis. This article provides an overview and comprehensive summary of the possible cardiotoxic side effects of important oncological therapies and offers possible practical strategies with respect to risk stratification, cardiological follow-up care and management approaches for chemotherapy-induced left ventricular dysfunction.

Ultrasound is an important diagnostic tool especially in emergency and intensive care medicine. It is always available at the bedside and shortens time to diagnosis. Many specialties have integrated ultrasound into diagnostic algorithms as part of the extended physical exam. Numerous differential diagnoses can be easily excluded using point-of-care ultrasound and therefore adequate treatment is initiated faster. Emergency or focused ultrasound is therefore of outstanding relevance to any emergency or critical care physician. Integration into medical school curricula is becoming more common tough no nationwide standards are in place yet.

Additional file 1: Appendix 1. Introductory letter, Information sheets A (Optimistic sheet) and B (Pessimistic sheet) and questionnaire with clinical cases (translated from French).

Based on a close collaboration between CEA and CNRS, a new hybrid magnet is being built at LNCMI-Grenoble. By combining a resistive insert, which is made of Bitter and polyhelix coils, with a large bore superconducting outsert, an overall continuous magnetic field of at least 43 T will be produced in a 34-mm warm bore aperture. The superconducting coil relies on the novel development of a Nb-Ti/Cu Rutherford cable-on-conduit conductor cooled down to 1.8 K by a bath of superfluid helium at atmospheric pressure and will produce a nominal magnetic field of 8.5 T in a 1.1-m cold bore diameter. After thorough reviews of the hybrid magnet design, which have anticipated possible upgrades of the maximum magnetic field produced, the project has entered in its production phase. The status and the next steps of the project will be reviewed highlighting the remaining technical challenges.

PURPOSE To model keratoconus (KC) using induced pluripotent stem cells (iPSC) generated from fibroblasts of both KC and normal human corneal stroma by a viral method. METHODS Both normal and KC corneal fibroblasts from four human donors were reprogramed directly by delivering reprogramming factors in a single virus using 2A "self-cleaving" peptides, using a single polycistronic lentiviral vector coexpressing four transcription factors (Oct 4, Sox2, Klf4, and Myc) to yield iPSC. These iPS cells were characterized by immunofluorescence detection using of stem cell markers (SSEA4, Oct4, and Sox2). The mRNA sequencing was performed and the datasets were analyzed using ingenuity pathways analysis (IPA) software. RESULTS The generated stem cell-like clones expressed the pluripotency markers, SSEA4, Oct4, Sox2, Tra-1-60, and also expressed pax6. Our transcriptome analysis showed 4300 genes, which had 2-fold change and 870 genes with a q-value of

A 47-year-old man presented with angina pectoris complaints in the chest pain unit. Due to psoriasis and psoriatic arthritis he had been systemically treated for 4 years. Because of an increased cardiovascular risk profile, coronary heart disease (CHD) was suspected and an invasive coronary diagnosis was performed. In the cardiac catheterization, CHD could be detected and treated in the same session. The risk of CHD in patients with psoriasis is increased due to a higher incidence of risk factors but also the disease itself. Patients with psoriasis should regularly undergo cardiovascular risk screening.

Focused echocardiography has become increasingly important for bedside diagnostics in acute medicine. Focused echocardiography can detect various cardiac pathologies, such as pericardial effusion, left ventricular dysfunction, right heart strain, relevant heart valve defects and dissection of the ascending aorta. Echocardiographic findings should be interpreted in the clinical context.

Mortality in patients with out-of-hospital cardiac arrest (OHCA) remains very high despite advances in resuscitation algorithms. Most of these patients die at the scene and do not reach hospital. It is currently the subject of discussion whether transport to hospital with ongoing cardiopulmonary resuscitation (CPR) improves survival and neurological outcome in patients with OHCA.The aim of this study was to identify predictors of survival and good neurological outcome in patients after OHCA who were transported to hospital with ongoing CPR.A total of 70 consecutive patients with refractory OHCA (mean age 54.7 ± 15 years) transported to hospital with ongoing CPR were retrospectively analyzed. Neurological outcome was assessed after 30 days based on the Glasgow-Pittsburgh cerebral performance category (CPC).After 30 days 82.9% of the patients enrolled in the trial died (CPC score of 5), 8 patients (11.4%) showed a good neurological recovery with CPC scores of 1-2 and 4 patients (5.7%) had a poor neurological outcome with CPC scores of 3-4. Predictors of good neurological outcome were witnessed arrest, initial defibrillatable rhythm and serum lactate levels on admission. In all patients with good outcome, the index event for OHCA was from cardiac causes.Selected patient collectives can benefit from transport to hospital with ongoing cardiopulmonary resuscitation (CPR).

An 81-year-old woman with infarct-related cardiogenic shock was admitted to the cardiac catheterization laboratory. Coronary angiography revealed an occlusion of the ramus interventricularis anterior. Due to incomplete flow after the percutaneous coronary intervention with implantation of three coronary stents and high thrombus burden, tirofiban was given as a bail out therapy. A central venous catheter (CVC) aimed at the internal jugular vein was incidentally inserted in the common carotid artery, resulting in acute dyspnea and a hemorrhagic shock due to a massive cervical hematoma. Although the CVC is a frequently used intervention in critical care, the procedure still carries some risks of iatrogenic injury. Knowledge about the emergency management of CVC-associated complications is therefore essential.

A 52-year-old man suffered an out-of-hospital cardiac arrest (OHCA) and bystander reanimation was immediately started. The initial electrocardiogram indicated ventricular fibrillation. After repetitive defibrillations as well as intravenous administration of amiodarone, a temporary return of spontaneous circulation (ROSC) could be established. Due to unstable cardiovascular conditions with recurrence of ventricular fibrillation, mechanical resuscitation with the help of the LUCAS™ device was initiated, and the patient was admitted to our hospital for emergency coronary angiography after a cumulative period of approximately 90 min. The initial blood gas analysis displayed a significant lactate acidosis with a pH value of 6.7. Therefore, in a multidisciplinary team, the decision was made against an extracorporeal membrane oxygenation and for a coronary angiography under continuation of mechanical resuscitation. After multiple stenting of the right coronary artery and left anterior descending coronary artery, permanent ROSC could be established. The patient was admitted to our intensive care unit, where he was further treated according to the S3-guideline for infarct-related cardiogenic shock. In the course of time, the patient was quickly extubated without any neurological deficits.

Eine 34-jahrige Patientin wurde nach erfolgreicher kardiopulmonaler Reanimation im kardiogenen Schock vorstellig. Fremdanamnestisch wurde eine Migrane angegeben. Die Notfallechokardiographie zeigte eine eingeschrankte linksventrikulare Pumpfunktion mit basomittventrikularer Hypokinesie und apikaler Hyperkontraktilitat. Die kraniale Computertomographie ergab den Hinweis auf eine stattgefundene massive Subarachnoidalblutung (SAB), sodass unter Berucksichtigung der Fremdanamnese (starkste Kopfschmerzen) die Diagnose einer SAB-assoziierten umgekehrten Takotsubo-Kardiomyopathie gestellt werden konnte. Im Rahmen einer SAB sollte stets an die Assoziation von extrazerebralen Organdysfunktionen, wie das Auftreten einer invertierten Takotsubo-Kardiomyopathie, gedacht werden.

Essential hypertension (EH) is a widespread disease and might be prevalent in apnea divers and master athletes. Little is known about the influence of EH and the antihypertensive drugs (AHD) on cardiovascular reactions to combined breath hold (BH) and exercise. In this pilot study, healthy divers (HCON) were compared with treated hypertensive divers with regard to heart rate (HR) and mean blood-pressure (MAP) responses to BH, exercise and the combination of both. Ten subjects with EH and ten healthy divers were tested. 3 different 20 s stimuli were applied: BH combined with 30 W or 150 W and 150 W without BH. The time-charts during the stress intervals and during recovery were compared. Subjects treated with an angiotensin-converting enzyme (ACE) inhibitor showed higher changes for MAP values if breath hold was performed. HR responses were obviously changed if a β-blocker was part of the medication. One subject showed extreme MAP responses to all stimuli and conspicuous HR if BH was involved. The modulation of HR-/MAP-response in EH subjects depends on the mechanisms of antihypertensive agents. The combination of an ACE inhibitor and a β-blocker may give the best protection. It is recommended to include short apnea tests in the fitness-to-dive examination to individually predict potential endangerment.

Hypothermia-induced J‑ or so-called Osborn waves can be detected under therapeutic hypothermia in approximately 20-40% of cases. The occurrence of J‑waves in the context of the targeted temperature management after cardiopulmonary resuscitation is characteristic, but not pathognomonic for hypothermia. An electrocardiographic diagnosis under hypothermia after cardiac arrest should always be done with caution due to the various hypothermia-associated electromechanical changes of the myocardium.

Tricuspid valve regurgitation is frequently found as a result of right ventricular remodeling due to advanced left heart diseases. Drug treatment is limited to diuretics and the cardiac or pulmonary comorbidities. Due to the high risk only a small percentage of patients are amenable to surgical treatment of tricuspid regurgitation in those who undergo left-sided surgery for other reasons. Catheter-based procedures are an attractive treatment alternative, particularly since the strong prognostic impact of tricuspid regurgitation suggests an unmet need of treatment, independent of the underlying heart disease. A vast amount of clinical experience exists for the MitraClip system for treatment of mitral regurgitation. A first case series shows that the application for treatment of tricuspid regurgitation is technically feasible, seems to be safe and the degree of valve regurgitation can be reduced. In this review the background of tricuspid regurgitation treatment is summarized and first experiences and perspectives with the MitraClip system are assessed.

Circulatory insufficiency is often understood as symptomatic hypotension due to various causes. The clinical result of circulatory dysregulation is arterial hypotension. The manifestation of hypotension is often divided into chronic and acute forms. Chronic hypotension can be distinguished etiopathogenetically into primary and secondary hypotension. Acute hypotension is usually equated to circulatory shock. While patients with chronic hypotension should be seen primarily by their general practitioner, patients with acute hypotension and a frequently severe clinical manifestation should be evaluated in the emergency department or, if there is a specific cause, directly in the acute clinic. Standardization of diagnostic and therapeutic pathways in both out- and inpatient care-not only for the management of circulatory weakness-would be an improvement not only in regards to patient care, but also with respect to healthcare economics.

The so-called point-of-care ultrasound (POCUS) is of increasing importance for diagnostics and therapy control in intensive care medicine. Based on focused thorax sonography, echocardiography, and abdominal sonography, the most important working and differential diagnoses can be demonstrated or excluded depending on the leading symptom. Sonographic-based algorithms allow a structured evaluation especially of patients with the common leading symptoms dyspnea and thoracic pain.

A 94-year-old patient with cardiogenic shock due to myocardial infarction was admitted via the emergency room. A coronary angiography and intensive care were requested. The need for care due to dementia was known. After case discussion in the interdisciplinary and multiprofessional treatment team, the decision for a palliative care concept in the form of symptom control was made in the emergency room, taking into account the patient's medical history, the current situation, and the presumed patient consent. The integration of medical ethics aspects and palliative medicine into "geriatric emergency medicine" will present a challenge in the future.

The establishment of primary percutaneous interventions for the treatment of myocardial infarction, increasingly complex coronary and noncoronary interventions in severely ill patients, and the increasing rise in the number of catheter examinations in elderly and morbid patients due to demographics frequently necessitates involvement of intensive care physicians for primary care of unstable patients and management of complications within the cath lab. In the context of complication and risk management, therefore, all cardiac catheter labs should develop a checklist in collaboration with the respective emergency/intensive care team. Team-oriented interdisciplinary management through standardization of emergency scenarios remains the key to success, despite all progress.

Die Lungensonographie beschrankte sich bisher auf den Ausschluss oder Nachweis von Pleuraergussen und die sonographisch-gesteuerte Pleurapunktion. In den letzten Jahren hat die Bedeutung der Lungensonographie als Diagnostikum in der Notfall- und Intensivmedizin zugenommen. Einfachheit und bettseitige Anwendbarkeit machen die Lungensonographie zu einem bedeutenden Verfahren fur alle Akutsituationen bei Dyspnoe oder bei Oxygenierungsproblemen. Verschiedene Lungenerkrankungen, wie der Pleuraerguss, die pulmonalvenose Stauung und das Lungenodem, die Pneumonie und der Pneumothorax, konnen unter Notfallbedingungen mittels Lungensonographie sehr schnell erfasst werden.

A CEA-CNRS French collaboration is currently developing a new hybrid magnet to produce in a first step a continuous magnetic field of 43 T in a 34-mm warm bore aperture. This magnet combines a resistive insert, composed of Bitter and polyhelix coils, and a large bore superconducting “outsert.” The superconducting coil is based on the novel development of a Nb-Ti/Cu Rutherford Cable On Conduit Conductor (RCOCC) cooled down to 1.8 K by a bath of superfluid helium at atmospheric pressure. It aims at producing a nominal magnetic field of 8.5 T in a 1.1-m cold bore diameter. The specifications of the RCOCC will be presented together with the design and parameters of the cryogenic system. The solution to reduce the coupling between resistive and superconducting coils will be recalled as well as the constraints for designing the mechanical structure. The design study phase is coming to an end. The status of the conductor production and the next steps of the project are presented.

Resume Introduction La sante neonatale demeure une preoccupation majeure dans nos pays aux conditions d’accueil du nouveau-ne tres difficiles. Ce travail vise a analyser les facteurs de risque de deces des nouveau-nes de faible poids de naissance dans des structures sanitaires urbaines au sud du Sahara. Patients et methodes Il s’agit d’une etude retrospective de type descriptif du 1er janvier 2006 au 31 decembre 2010, portant sur les antecedents gestationnels et les parametres epidemiologiques cliniques de nouveau-nes de faible poids de naissance ( Resultats Le taux de prematurite etait de 60,8 %. Les nouveau-nes de faible poids de naissance ont constitue 64,8 % des hospitalisations avec un sex-ratio de 1,1. Trente-trois pour cent des meres etaient âgees de moins de 20 ans et 77,6 % des parturientes etaient des femmes au foyer. L’hypertension arterielle etait retrouvee dans 4,8. Le poids etait compris entre 1500 et 2000 g pour 33,2 %. Parmi les nouveau-nes, 25,7 % ont ete reanimes. La mortalite etait de 30,6 % et 50,8 % des deces survenaient dans les 48 premieres heures d’hospitalisation. Le score d’APGAR etait inferieur a 7 a une minute, l’accouchement par voie basse, le faible poids de naissance, la grossesse monofœtale, la duree d’hospitalisation inferieure ou egale a sept jours, la structure sanitaire de Saint-Camille ont ete les facteurs de risque significativement associes a la mortalite. Conclusion La mortalite neonatale precoce lors de faible poids de naissance demeure une preoccupation au Burkina Faso. Il est donc imperatif d’entreprendre des actions plus soutenues dans le sens d’une meilleure prevention et d’une prise en charge adequate des nouveau-nes (adoption de la methode kangourou, renforcer les moyens de reanimation du nouveau-ne…)

Hemodynamic monitoring is required in critically ill patients presenting with circulatory shock. Besides the clinical evaluation, noninvasive technologies can be used. Guidelines on volume resuscitation and cardiogenic shock already recommend bedside ultrasound as a diagnostic tool. To differentiate the cause of circulatory shock and monitor the effects of therapies, hemodynamic monitoring is necessary. This review discusses possibilities of the different invasive and noninvasive monitoring tools with a focus on the integration of clinical and sonographic parameters.

Anamnese und klinischer Befund: Eine 70-jahrige Patientin klagte nach einem heftigen Streit mit einem Hundebesitzer uber persistierende Angina pectoris und Belastungsdyspnoe, so dass sie sich 5 Tage nach dem Ereignis in unserer Klinik vorstellte. Untersuchungen: Das EKG zeigte T-Inversionen in den inferioren und anterioren Ableitungen sowie eine verlangerte QTc-Zeit (490 ms). Das NTproBNP war mit 6733 ng/l erhoht bei normalem Troponin T. Die anschliesende Echokardiographie und Herzkatheteruntersuchung konnte eine eingeschrankte linksventrikulare Pumpfunktion (EF 55 %) mit apikaler Akinesie nachweisen. Koronarangiographisch wurde eine koronare Makroangiopathie ausgeschlossen. In Zusammenschau aller Befunde wurde die Diagnose einer Stress-Kardiomyopathie, das sogenannte Tako-Tsubo-Syndrom, gestellt. Therapie und klinischer Verlauf: Eine Therapie der linksventrikularen Dysfunktion wurde leitliniengerecht eingeleitet. Im Rahmen der Nachkontrolle konnte einerseits eine Verbesserung der linksventrikularen Pumpfunktion jedoch andererseits ein neu aufgetretener linksventrikularer apikaler Thrombus nachgewiesen werden, so dass zusatzlich eine Antikoagulationstherapie begonnen wurde. Folgerung: Bei apikaler Akinesie im Rahmen eines Tako-Tsubo-Syndroms sollte stets an die Moglichkeit der Entstehung eines linksventrikularen Thrombus in nur wenigen Tagen gedacht werden.

Diabetes mellitus und Herzinsuffizienz zeigen eine hohe Koexistenz und begunstigen sich gegenseitig in der Entstehung. Die Koexistenz der beiden Erkrankungen ist mit einer sehr ungunstigen Prognose assoziiert. Es existiert praktisch keine Evidenz fur Behandlungsempfehlungen zur Pravention der Herzinsuffizienz bei Diabetes und zur antihyperglykamischen Therapie bei manifester Herzinsuffizienz. Die allgemein empfohlene Herzinsuffizienztherapie scheint hingegen bei Diabetikern genauso effektiv zu sein wie bei Nichtdiabetikern und sollte konsequent durchgefuhrt werden.

Nach einem vergleichsweise trivialen Verkehrsunfall stieg der 65-jahrige Unfallfahrer aus dem Fahrzeug und kollabierte kurz darauf. Zufallig vor Ort befindliche Polizeibeamte leiteten unverzuglich eine kardiopulmonale Reanimation ein. Ein Passant entnahm aus einem benachbarten Firmenfoyer den dort stationierten, frei zuganglichen Defibrillator. Nach Anbringen der Elektroden und Analyse des Defibrillators wurde ein Schock (200 Joule, biphasisch) ausgelost. Das zugrunde liegende Kammerflimmern wurde dadurch terminiert. In der Klinik ergab die Akutherzkatheteruntersuchung eine hochgradige, filiforme Stenose der proximalen rechten Koronararterie, die durch einen Stent versorgt wurde. Aufgrund der optimalen Basismasnahmen, der sofortigen notfallmedizinischen Versorgung und der erfolgreichen Revaskularisation war der Verlauf sehr gunstig; der Patient konnte ohne jegliche neurologische Defizite nach Hause entlassen werden. Der Fall zeigt beispielhaft, dass automatisierte externe Defibrillatoren im Rahmen der kardiopulmonalen Reanimation auch von Laien problemlos und sicher angewandt werden konnen.

It is necessary to know the specific pathobiology of a persistent epithelial defect to determine the strategy to be employed to assist in its repair. Lid position and function must be normal and any deficiency in the quantity and quality of the tears enhanced by tear preparations and closure of the lacrimal canaliculi. Adverse drug effects must be eliminated. Multiple corneal punctures and excision of reduplicated basal lamina have virtually eliminated the problem of recurrent corneal erosions. Control of any inflammatory process also speeds healing. Vitamin supplements, especially A, reverse defects associated with xerophthalmia. In any of these diseases, mechanical treatments consisting of soft contact lenses for persistent epithelial defects and collagen shields for the delivery of antibiotics or steroids to the eye may be employed. Tarsorrhaphy relieves the problem of persistent epithelial defects in neurotrophic keratitis and a variety of other conditions characterized by persistent surface breakdown. Preliminary data from open label studies of epidermal growth factors and fibronectin are encouraging but not yet conclusive.

Sympathovagal imbalance plays an important role in the progression of heart failure with reduced ejection fraction. Baroreflex activation therapy (BAT), i. e. electrical stimulation of baroreceptors located at the carotid sinus, can reduce sympathetic and enhance parasympathetic tone. Large animal studies on BAT demonstrated improvements in cardiac function, arrhythmogenic risk and a survival benefit compared to untreated controls. The recently published Neo Randomized Heart Failure Study, the first multicenter, randomized and controlled trial of optimal medical and device therapy alone or plus BAT in patients with a left ventricular ejection fraction ≤ 35 %, demonstrated a reasonable safety profile of BAT in this severely ill patient population and no relevant interactions with other devices. The study found significant improvements in the New York Heart Association (NYHA) class of heart failure, quality of life as well as 6 min walking distance and data pointed to a reduction in hospitalization rates. Moreover, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were significantly reduced. This review gives an overview on BAT for the treatment of heart failure with reduced ejection fraction, from the rationale and animal experiments to the most recent clinical data and future perspectives.

Background We aimed to examine the association between chocolate intake and the risk of incident heart failure in a UK general population. We conducted a systematic review and meta-analysis to quantify this association. Methods and results We used data from a prospective population-based study, the European Prospective Investigation into Cancer (EPIC)-Norfolk cohort. Chocolate intake was quantified based on a food frequency questionnaire obtained at baseline (1993–1997) and incident heart failure was ascertained up to March 2009. We supplemented the primary data with a systematic review and meta-analysis of studies which evaluated risk of incident heart failure with chocolate consumption. A total of 20,922 participants (53% women; mean age 58 ± 9 years) were included of whom 1101 developed heart failure during the follow up (mean 12.5 ± 2.7 years, total person years 262,291 years). After adjusting for lifestyle and dietary factors, we found 19% relative reduction in heart failure incidence in the top (up to 100 g/d) compared to the bottom quintile of chocolate consumption (HR 0.81 95%CI 0.66–0.98) but the results were no longer significant after controlling for comorbidities (HR 0.87 95%CI 0.71–1.06). Additional adjustment for potential mediators did not attenuate the results further. We identified five relevant studies including the current study (N = 75,408). The pooled results showed non-significant 19% relative risk reduction of heart failure incidence with higher chocolate consumption (HR 0.81 95%CI 0.66–1.01). Conclusions Our results suggest that higher chocolate intake is not associated with subsequent incident heart failure., Highlights • Whether chocolate consumption increases or decreases the risk of heart failure remains controversial. • Our results suggest that higher chocolate intake is not associated with subsequent incident heart failure. • Our meta-analysis found consistent findings across all studies that chocolate consumption does not increase the risk of incident heart failure. • Evidence suggests that chocolate consumption does not increase risk of heart failure at the general population level.

The mortality in patients with cardiogenic shock after out-of-hospital cardiac arrest (OHCA) remains high despite advances in resuscitation and early revascularization strategies. The use of mild therapeutic hypothermia (MTH) for improvement of survival and neurological outcome in patients with cardiogenic shock is currently subject to renewed discussion.The aim of this study was the detection of risk factors for mortality and morbidity in patients under MTH in cardiogenic shock following preclinical resuscitation for OHCA.A total of 80 consecutive patients in cardiogenic shock after successful resuscitation (mean age 60 ± 3.2 years) treated with MTH were retrospectively analyzed. Patients were cooled to 33 °C for 24 h using an endovascular cooling device. Neurological outcome was assessed after 2 months based on the Glasgow-Pittsburgh cerebral performance category (CPC) and correlated with various blood parameter values.After 2 months 31 patients (39 %) showed a good neurological recovery with CPC scores of 1-2, 20 patients (25 %) had a poor neurological outcome with CPC scores of 3-4 and 29 (36 %) patients enrolled in the trial died (CPC 5). Patients with a poor outcome showed significantly higher mean serum levels for lactate, creatinine and urea. In addition, these patients showed a continuous increase of serum neuron-specific enolase (NSE) values in contrast to patients with a good outcome (∆ NSE from admission to day 1, CPC 1 and 2: - 10.6 ± 3 µg/l and CPC 3-5: 33 ± 12 µg/l, p = 0.02).Changes in the course of serum creatinine, urea and NSE levels within the first 72 h after OHCA could provide valuable additional information for the early assessment of the neurological prognosis in patients treated with MTH.